The Experience of Survivors of Firearm Suicide Attempts: A Retrospective Case Series.

Objective: We sought to identify people who survived firearm suicide attempts to describe the acute stressors, substance use, and mental health conditions related to the attempt. Background: Most firearm deaths in the United States are the result of suicide. Because firearm suicide attempts have a case fatality rate of approximately 90%, little is known about the precipitating factors that lead to firearm suicide attempts. Methods: We conducted a retrospective case series of patients admitted to a large hospital system between 2000 and 2019 who survived intentional, self-inflicted gunshot wounds to the head. Through the electronic medical record, we collected information about acute stressors, substance use, and mental health diagnoses before or at the time of the suicide attempt. Results: Thirty-four patients were included in the study cohort. Patients were predominantly White (74%) and male (88%), with a mean age of 44 (range, 14-82). Nineteen (56%) patients were acutely intoxicated with alcohol upon hospitalization and 17 (50%) patients had a positive urine drug screen. Acute stressors involving interpersonal relationships (53%), work/school (32%), and legal disputes (18%), among others, were documented in 82% of patients. Most patients (65%) had been diagnosed with depression before their index hospitalization. Most patients were discharged to an acute rehabilitation center (41%) or an inpatient psychiatric facility (41%). Conclusions: Acute stress and alcohol intoxication were common in this cohort of patients who attempted suicide using firearms. These data offer an ability to learn from the experience of survivors of firearm suicide attempts, a rare population.

Outcomes of Combined Opioids and Benzodiazepines Consumption in Elderly Trauma: A Retrospective Cohort Study.

BACKGROUND: Acute substance intoxication is associated with traumatic injury and worse hospital outcomes. The objective of this study was to evaluate the association between simultaneous opioids and benzodiazepines (OB) use and hospital outcomes in elderly trauma patients. METHODS: We performed a retrospective analysis using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 database. We included trauma patients (age ≥ 65 years) examined by urine toxicology within 24 hours of presentation. The primary outcome was in-hospital mortality. Secondary outcomes included hospital and ICU lengths of stay (HLOS AND ICULOS), in-hospital complications (eg, ventilator-associated pneumonia), unplanned intubation, and duration of mechanical ventilation. Patients were stratified being both positive for opioids and benzodiazepines (OB+) or not (OB-) based on having positive or negative drug screen for both drugs, respectively. A 1:1 propensity score matching was performed controlling for demographics (eg, age and sex), comorbidities (eg, alcoholism), and injury characteristics. RESULTS: Of 77,311 tested patients, 849 OB+ were matched to OB- patients. Compared to OB- group, OB+ patients were more likely to have unplanned intubation (26 [3.1%] vs 8 [0.9%], P = 0.002) and had prolonged HLOS (≥2 days: 683 [84.0%] vs 625 [77.8%], P = 0.002). There were no differences in all other outcomes (P > 0.05). CONCLUSIONS: The OB intake is associated with higher incidence of unplanned intubation and longer HLOS in elderly trauma patients. Early identification of elderly trauma patient with OB+ can help provide necessary pharmacologic and behavioral interventions to treat their substance use and potentially improve outcomes.

Day to Day Advocacy by Pediatric Health Care Providers.

This manuscript highlights the impressive advocacy work that members of the American Academy of Pediatrics have achieved and serves to inspire pediatric health care providers of all specialties to pursue such efforts beyond the acute physical need of the child. This article represents one of the Symposia presented at the 2023 American Academy of Pediatrics Section on Surgery.

Estimating Community Disruption from Nighttime Gunshots in 6 U.S. Cities, 2015 to 2021.

BACKGROUND: Gunshots affect those directly involved in an incident and those in the surrounding community. The community-level impact of nighttime gunshots, which may be particularly disruptive to the sleep of nearby community members, is unknown. OBJECTIVE: Our aim is to estimate the number of people potentially affected by nighttime gunshots and the relationship between nighttime gunshots and median household income in the USA. DESIGN: We collected publicly available data on the timing and location of gunshots in six U.S. cities (Baltimore, MD; Boston, MA; Washington, D.C.; New York, NY; Philadelphia, PA; and Portland, OR) from 2015 to 2021. We then analyzed the data by computing rate ratios (RRs) to compare the frequency of gunshots during nighttime hours (6:00 pm to 5:59 am) versus daytime hours (6:00 am to 5:59 pm). Additionally, we used geospatial mapping to create choropleth maps to visualize the variation in nighttime gunshot density across cities. We estimated, using city-wide population, person-nights potentially impacted by the sound of gunshots within areas of 0.2- (low) and 0.5-mile (high) radius. Finally, for five of six cities where data on median household income were available by census tract, we built nonlinear regression models to estimate the relationship between the number of nighttime gunshots and median household income. KEY RESULTS: We analyzed 72,236 gunshots. Gunshots were more common during the nighttime than daytime (overall RR = 2.5). Analyses demonstrated that the low estimates for the mean annual number of person-nights impacted by nighttime gunshots were 0.4 million in Baltimore and Portland, 1.3 million in Philadelphia, 1.6 million in Boston, 2.9 million in New York City, and 5.9 million in Washington. The number of nighttime gunshots was inversely related to median household income. CONCLUSIONS: Nighttime gunshots are prevalent, particularly in low-income neighborhoods, and may have under-recognized effects on the surrounding community.

Quantifying Pediatric Gun Violence by Location, Time of Day, and Day of Week.

BACKGROUND: Firearm injuries are the leading cause of pediatric deaths. The objective of this study was to describe the location and timing of pediatric firearm injuries and to determine the proportion of these injuries that occur within schools in the United States. METHODS: In this retrospective cohort study, we used national emergency medical services (EMS) data from 2019 to evaluate dispatches to firearm injuries involving school-aged children (age 5-18). We extracted incident location type, patient demographics, number of patients on scene, and injury intent. RESULTS: We identified 4764 EMS dispatches for firearm injuries in school-aged children during 2019. Assault was the most common cause of injury (53.9 %), followed by unintentional shootings (12.1 %) and self-inflicted injuries (6.1 %). Most incidents involved a single patient (91.4 %). Private residence (51.5 %) was the most common location, followed by street/road (23.8 %). 81 firearm injuries (1.7 %) occurred in a school. Private residence was the most common location of injury across all injury intents. During school hours, most firearm injuries occurred in a private residence (51.6 %) or on a street/road (19.9 %). A total of 63 dispatches (1.3 %) were considered a mass casualty incident, of which 9 (14 %) occurred in a school. CONCLUSIONS: Regardless of injury intent or time of day, the most common location for pediatric firearm injuries was a private home. Firearm injuries within schools were far less frequent. In designing prevention strategies, our data calls for renewed focus on preventing children from accessing firearms in the home and instituting comprehensive, community-based after school programs. TYPE OF STUDY: Retrospective cohort. LEVEL OF EVIDENCE: III.

Pediatric Surgery Firearm Injury Collaborative Symposium.

Injury from a firearm is now the leading cause of death of children and youth under age 19 in the United States (U.S.) [1] and the incidence of these deaths continues to increase each year [2]. For every death from firearm violence, there are several young people who have been injured by a bullet but not killed. As pediatric surgeons, we are on the front lines of treating these young patients. We have the unforgettable memories of delivering the horrible news to parents in "quiet rooms." [3]. As these injuries fall within our scope of practice, it is incumbent on us as professionals to work to prevent these injuries, apply best practices and work for the best pathways to recovery for our patients who do survive. There is a diverse community of pediatric surgeons tackling this public health problem in a variety of ways [4]. In a pre-meeting symposium at the APSA 2023 Annual meeting, we brought together a community of pediatric surgeons working on this critical area. The following summarizes the presentations of the symposium, with topics including Risk Factors, Injury Prevention, Treatment, Public Initiatives, and National Collaborative Efforts. TYPE OF STUDY: Review Article, Proceedings of a Symposium. LEVEL OF EVIDENCE: 1 through 4 all presented.

Characterizing Gun Violence by Time, Day of the Week, Holidays, and Month in 6 US Cities, 2015-2021.

Developing interventions to prevent firearm-related violence and to address its consequences requires an improved understanding of when these violent events are most likely to occur. We explored gunshot events in 6 of the most populated cities in the United States by time of day, day of week, holiday/non-holiday, and month using publicly available datasets. In some of these cities, gunshot events occurred most often at nighttime, on holidays and weekends, and during summer months, with significant interaction effects. There were also time-related changes in characteristics of the victims. Primary prevention efforts aimed at curbing firearm-related violence should consider these differential risks.

Promoting Firearm Injury Prevention and Advocacy as Pediatric Surgeons: A Call to Action From the APSA/AAP Advocacy Committee.

Firearm injuries have become the leading cause of death among American children. Here we review the scope of the problem, and the pivotal role pediatric surgeons have in preventing pediatric firearm injury. Specific methods for screening and counseling are reviewed, as well as how to overcome barriers. Community and hospital resources as well as organizational efforts are discussed. Finally, a path for surgeon advocacy is outlined as is a call to action for the pediatric surgeon, as we are uniquely poised to identify pediatric patients and deliver timely interventions to reduce the impact of firearm violence. LEVEL OF EVIDENCE: Level IV.

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study.

Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

Underuse and Variability in Substance Use Screening Among Adult Trauma Patients in the U.S.: A Nationwide Retrospective Cohort Study.

OBJECTIVE: To characterize the rates and variability in substance screening among adult trauma patients in the U.S. SUMMARY BACKGROUND DATA: Emergency Department trauma visits provide a unique opportunity to identify patients with substance use disorders. Despite the existence of screening guidelines, underscreening and variability in screening practices remain. METHODS: Retrospective cohort study including adult trauma patients (18- 64-year-old) from the ACS-TQIP 2017-18 database. Multivariable logistic regressions were performed to adjust for demographics, clinical, and facility factors, and marginal probabilities were calculated using these multivariable models. The primary outcomes were substance screening and positivity, which were defined relative to the observation-weighted grand mean (mean). RESULTS: 2,048,176 patients were contained in the TQIP dataset, 809,878 (39.5%) were screened for alcohol (20.8% positive), and 617,129 (30.1%) were screened for drugs (37.3% positive). After all exclusion criteria were applied, 765,897 patients were included in the analysis, 394,391 (52.9%) were screened for alcohol (22.1% tested positive), and 279,531 (36.5%) were screened for drugs (44.3% tested positive). Among the patients included in our study, significant variability in screening rates existed with respect to demo-graphic, trauma mechanism, injury severity, and facility factors. Furthermore, in several cases, patient subpopulations who were less likely to be screened were in fact more likely to screen positive or vice versa. CONCLUSIONS: Effective substance-screening guidelines should be predicated on achieving universal screening. Current lapses in screening, along with the observed variability, likely affect different patient populations in disparate manners and lead to both under-detection as well as waste of valuable resources.

Where Are the Questions About Firearms?: An Analysis of US Federal Public Health Survey Data Infrastructure.

OBJECTIVE: To evaluate existing federal survey data infrastructure pertaining to firearms and firearm-related violence. BACKGROUND: Firearm-related violence results in >40,000 deaths in the United States each year. Limited federal investments over the past 25 years have restricted a systematic approach to federal data collection related to firearms. METHODS: We conducted a systematized review of the 22 continuously administered public health surveys in the US Federal Statistical System conducted between 1995 and 2020. Surveys were included if they addressed 1 of 4 areas of inquiry: (1) firearms; (2) exposure to or experience of firearm-related, intimate partner, or other interpersonal violence; (3) substance use and substance use disorder; (4) behavioral health. Descriptive statistics were used to report the frequency of relevant questions. RESULTS: Nine of 22 surveys were focused on one of these domains and included in this analysis, 7 focused on adults (total 128 survey administrations over the study period) and 2 on youth and adolescents (total 30 administrations). Among all adult surveys, questions related to firearm use were asked 20% of the time, firearm-related violence 4%, firearm ownership 23%; in youth surveys, firearm use was addressed 0 times, firearm-related violence 57%, and firearm ownership 90%. CONCLUSIONS: Reliable national data are critical to understanding firearm-related violence as well as to developing, implementing, and evaluating public health measures to address it. Improving the consistency of questions pertaining to firearm access and experiences of violence in federal surveys offers an opportunity to improve national data infrastructure.

Associations of cephalad drainage in neonatal veno-venous ECMO - A mixed-effects, propensity score adjusted retrospective analysis of 20 years of ELSO data.

BACKGROUND: Neurologic complications can occur during neonatal Veno-Venous (VV) ECMO. The addition of a cephalad drainage cannula (i.e., VVDL+V) to dual lumen cannulation (i.e., VVDL) has been advocated to reduce such complications, but previous studies have presented mixed results. METHODS: Data from the ECMO Registry of the Extracorporeal Life Support Organization was used to extract all neonates (≤28 days old) who underwent VV ECMO for respiratory support between 2000 and 2019. Primary outcomes were mortality, conversion to Veno-Arterial (VA) ECMO, pump flows, and complications. A mixed-effects, propensity score adjusted analysis was performed. RESULTS: 4,275 neonates underwent VV ECMO, 581 (13.6%) via VVDL+V cannulation, and 3,694 (86.4%) via VVDL. On unadjusted analyses, VVDL+V patients had higher rates of mortality (25.5% vs 19.0%, p<0.001), conversion to VA ECMO (14.5% vs 4.1%, p<0.001), and higher pump flows at 4 h from ECMO initiation (112.7 vs 105.5 mL/Kg/min, p<0.001), but lower at 24 h (100.3 vs 104.0 mL/Kg/min, p = 0.004), and a higher proportion of them experienced hemorrhagic (29.3% vs 18.3%, p<0.001), cardiovascular (60.8% vs 45.8%, p<0.001), and mechanical (42.5% vs 32.6%, p<0.001) complications compared to VVDL patients. After adjusting for propensity scores and the multi-level nature of ELSO data, there were no differences in neurologic outcomes, pump flows, or mortality. Rather, VVDL+V cannulation was associated with higher rates of conversion to VA ECMO (adjusted odds ratio [AOR] 43.3, 95% CI 24.3 - 77.4, p<0.001), and increased mechanical (AOR 2.2, 95% CI 1.6 - 3.0, p<0.001) and hemorrhagic (AOR 2.0, 95% CI 1.4 - 3.0, p<0.001) complications. CONCLUSIONS: In this analysis, VVDL+V cannulation was not associated with any improvement in neurologic outcomes, pump flows, or mortality, but was rather associated with higher rates of conversion to Veno-Arterial ECMO, mechanical, and hemorrhagic complications.

Variability of Pediatric Cervical Spine Clearance Protocols: A Systematic Review.

OBJECTIVE: The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. BACKGROUND DATA: Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. METHODS: A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. CONCLUSIONS: Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

Racial and Social Determinants of Civilian Gunshot Wounds to the Head.

Objective: To assess the clinical, racial, and social characteristics of victims of Gunshot wounds (GSWs) to the head and assess for associations between these factors and outcomes. Summary Background Data: Previous literature has not focused on the association of race and socioeconomic factors with these specific injuries. Methods: We identified patients with GSWs to the head who presented to 2 urban academic medical centers between 1998 and 2020, and extracted patient-level demographic data, information about the clinical and surgical course, and outcomes at discharge and follow-up. Results: The cohort included 250 patients, 90% (n = 226) of whom were male, with a mean age of 28 years. Forty-five percent were white (n = 112), 19% Black (n = 48), 18% Latinx (n = 45), with 6% "other" (n = 16), and 12% "unknown" (n = 29). The majority of patients presented with assault-related trauma (n = 153, 61%) as compared to self-inflicted injuries (n = 97, 39%). Across the entire cohort, sex, age, race, and median income by ZIP code were not significant predictors of outcome. Victims of assault by GSW to the head were more likely to be age 18 or younger (OR 5.26, P = 0.01), between the ages of 19 and 33 years (OR 4.7, P = 0.001), Black (OR 6.66, P < .001), and Latinx (OR 2.65, P = 0.03). Most patients (n = 155, 63%) had a poor functional outcome (modified Rankin Score 3-6) at discharge. Conclusion: Age, race, and income status were not independent predictors of mortality or functional outcome at discharge in our population. Assault-related GSWs to the head mostly involved young Black or Latinx men of lower socioeconomic status, while self-inflicted injuries were largely seen in older white men.

The impact of broadening COVID-19 testing eligibility on communities of color - A lesson for overcoming structural barriers to health care.

CDC guidelines for COVID-19 testing in March 2020 did not prioritize underserved communities. We present the effect that expanding COVID-19 testing had for residents of the predominantly Hispanic city of Chelsea, MA, which had the highest case rate in the state. Results were compared to another city with similar demographics, Lynn, MA, where testing eligibility remained unchanged. Institutional data were used to identify outpatient visits for influenza-like illness or COVID-19 exposure, COVID-19 tests, and hospitalizations for confirmed COVID-19 between 3/30/2020-4/28/2020. Multivariable logistic regressions were used to compare outcomes before and after the change in testing eligibility occurred on 4/13/2020. A total of 3,060 patients were included, 1,374 Chelsea residents and 1,686 Lynn residents. After guidelines changed, Chelsea residents were more likely to present as outpatients (adjusted odds ratio [AOR] 4.2, p < 0.001) and less likely to be hospitalized (AOR 0.2, p < 0.001). They were more likely to be tested (AOR 8.8, p < 0.001), but less likely to test positive (AOR 0.6, p = 0.05). Lynn residents were also more likely to be tested after 4/13/2020 (AOR 1.9, p < 0.001), but no significant differences in visit acuity or test positivity were observed. This study demonstrates how broadening testing eligibility for one highly affected, predominantly Hispanic community was associated with an increase in outpatient presentations and a concomitant decrease in test positivity and hospitalizations. These results highlight the impact of improved access to care on utilization of services among underserved communities, a lesson that is especially crucial as we continue to grapple with the COVID pandemic.

Development and Implementation of a Novel Case-Based Gun Violence Prevention Training Program for First-Year Residents.

PROBLEM: Gun violence results in approximately 40,000 deaths in the United States each year, yet physicians rarely discuss gun access and firearm safety with patients. Lack of education about how to have these conversations is an important barrier, particularly among trainees. APPROACH: A 2-part training curriculum was developed for first-year residents. It included (1) a didactic presentation outlining a framework to understand types of firearm-related violence, describing institutional resources, and reviewing strategies for approaching discussions about firearms with patients, and (2) interactive case scenarios, adjusted for clinical disciplines, with standardized patients. Before and after the training, participants completed surveys on the training's relevance, efficacy, and benefit. Standardized patients provided real-time feedback to participants and completed assessments based on prespecified learning objectives. OUTCOMES: In June-August 2019, 148 first-year residents in internal medicine (n = 74), general surgery (n = 12), emergency medicine (n = 15), pediatrics (n = 22), psychiatry (n = 16), and OB/GYN (n = 9) completed the training. Most (70%, n = 104) reported having no prior exposure to gun violence prevention education. Knowledge about available resources increased among participants from 3% (n = 5) pretraining to 97% (n = 143) post-training. Awareness about relevant laws, such as Extreme Risk Protection Orders, and their appropriate use increased from 3% (n = 4) pretraining to 98% (n = 145) post-training. Comfort discussing access to guns and gun safety with patients increased from a median of 5 pretraining to 8 post-training (on a scale of 1-10, with higher scores indicating more comfort). NEXT STEPS: Delivery of a case-based gun violence prevention training program was effective and feasible in a single institution. Next steps include expanding the training to other learners (across undergraduate and graduate medical education) and institutions and assessing how the program changes practice over time.